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Orthopaedic
Knowledge
Update
Hip and Knee Reconstruction
The Hip Society

The Knee Society
Editors
Michael A. Mont, MD
Michael Tanzer, MD, FRCSC
Orthopaedic
Knowledge
Update
Hip and Knee Reconstruction
Editors
Michael A. Mont, MD Michael Tanzer, MD, FRCSC
Chairman Jo Miller Chair and Professor of Surgery
Department of Orthopaedic Surgery Division of Orthopaedic Surgery
Cleveland Clinic Foundation McGill University
Cleveland, Ohio Montreal, Quebec, Canada
Developed by The Hip Society

and The Knee Society
Board of Directors, 2016-2017 The material presented in Orthopaedic
Gerald R. Williams Jr, MD Knowledge Update: Hip and Knee Recon-
President struction 5 has been made available by the
American Academy of Orthopaedic Surgeons
William J. Maloney, MD for educational purposes only. This material is
First Vice-President not intended to present the only, or necessarily
David A. Halsey, MD best, methods or procedures for the medical
Second Vice-President situations discussed, but rather is intended
to represent an approach, view, statement, or
M. Bradford Henley, MD, MBA
opinion of the author(s) or producer(s), which
Treasurer
may be helpful to others who face similar
David D. Teuscher, MD situations.
Past-President Some drugs or medical devices demonstrated
Basil R. Besh, MD in Academy courses or described in Academy
print or electronic publications have not been
Lisa K. Cannada, MD
cleared by the Food and Drug Administration
Howard R. Epps, MD (FDA) or have been cleared for specific uses
Daniel C. Farber, MD only. The FDA has stated that it is the respon-
sibility of the physician to determine the FDA
Brian J. Galinat, MD, MBA clearance status of each drug or device he or
Daniel K. Guy, MD she wishes to use in clinical practice.
Lawrence S. Halperin, MD Furthermore, any statements about commer-
cial products are solely the opinion(s) of the
Amy L. Ladd, MD author(s) and do not represent an Academy
Brian G. Smith, MD endorsement or evaluation of these products.
These statements may not be used in advertis-
Ken Sowards, MBA
ing or for any commercial purpose.
Karen L. Hackett, FACHE, CAE (ex officio) All rights reserved. No part of this publica-
tion may be reproduced, stored in a retrieval
Staff system, or transmitted, in any form, or by any
Ellen C. Moore, Chief Education Officer means, electronic, mechanical, photocopying,
Hans Koelsch, PhD, Director, Department of recording, or otherwise, without prior written
Publications permission from the publisher.
Lisa Claxton Moore, Senior Manager, Book
Published 2017 by the
Program
American Academy of Orthopaedic Surgeons
Steven Kellert, Senior Editor 9400 West Higgins Road
Kathleen Anderson, Senior Editor Rosemont, IL 60018
Courtney Dunker, Editorial Production Copyright 2017
Manager by the American Academy of Orthopaedic
Abram Fassler, Publishing Systems Manager Surgeons
Suzanne O’Reilly, Graphic Designer
Library of Congress Control Number:
Susan Morritz Baim, Production Coordinator 2016947582
Karen Danca, Permissions Coordinator ISBN: 978-1-62552-550-5
Printed in the USA
Charlie Baldwin, Digital and Print Production
Specialist
Hollie Muir, Digital and Print Production
Specialist
Emily Douglas, Page Production Assistant
Sylvia Orellana, Publications Assistant
iv Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 © 2017 American Academy of Orthopaedic Surgeons
Acknowledgments
Editorial Board The Knee Society Executive Board, 2016
Orthopaedic Knowledge Update: Hip and Thomas P. Sculco, MD
Knee Reconstruction 5 President
Michael A. Mont, MD Adolph V. Lombardi, Jr, MD, FACS
Chairman 1st Vice President
Department of Orthopaedic Surgery
Robert L. Barrack, MD
Cleveland Clinic Foundation
2nd Vice President
Cleveland, Ohio
Mark W. Pagnano, MD
3rd Vice President
Jo Miller Chair and Professor of Surgery Michael E. Berend, MD
Division of Orthopaedic Surgery Secretary
McGill University John J. Callaghan, MD
Montreal, Quebec, Canada Treasurer
Thomas P. Vail, MD
The Hip Society Executive Board, 2016 Immediate Past President
Harry E. Rubash, MD
Thomas K. Fehring, MD
President
Past President
Kevin L. Garvin, MD
Stephen J. Incavo, MD
1st Vice President
Education Committee Chair
Douglas E. Padgett, MD
Keith R. Berend, MD
2nd Vice President
Education Committee Chair Elect
Craig J. Della Valle, MD
Mark P. Figgie, MD
Secretary
Membership Committee Chair
Joshua J. Jacobs, MD
Christopher L. Peters, MD
Treasurer
Membership Committee Chair Elect
Daniel J. Berry, MD
Michael J. Dunbar, MD, FRCSC, PhD
Immediate Past President
Research Committee Chair
Kevin J. Bozic, MD, MBA
Craig J. Della Valle, MD
Education Committee Chair
Member-At-Large
Richard Iorio, MD
Membership Committee Chair
Member-At-Large
Richard Iorio, MD
Bassam A. Masri, MD, FRCSC
Research Committee Chair
Technology Committee Chair (Ex-Officio)
Donald Garbuz, MD, MHSc, FRCSC
Member-At-Large
Adolph V. Lombardi, Jr, MD, FACS
Fellowship & Mentorship Committee Chair
(Ex-Officio)
© 2017 American Academy of Orthopaedic Surgeons Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 v
Explore the full portfolio of AAOS educational programs and publications
across the orthopaedic spectrum for every stage of an orthopaedic surgeon’s
career, at www.aaos.org. The AAOS, in partnership with Jones & Bartlett
Learning, also offers a comprehensive collection of educational and training
resources for emergency medical providers, from first responders to critical
care transport paramedics. Learn more at www.aaos.org/ems.
Contributors
Mansour Abolghasemian, MD John W. Barrington, MD
Assistant Professor Co-Director, Surgeon
Department of Orthopedic Surgery Joint Replacement Center at Baylor Medical
Shafa Hospital, Iran University of Medical Center of Frisco
Sciences Plano Orthopedic Sports Medicine & Spine
Tehran, Iran Center
Plano, Texas
Anthony Albers, MD, FRCSC
Adult Hip and Knee Reconstruction Fellow Wael K. Barsoum, MD
Department of Orthopaedics Vice Chairman
University of British Columbia Department of Orthopaedic Surgery
Vancouver, British Columbia, Canada Cleveland Clinic
Cleveland, Ohio
Ram K. Alluri, MD
Research Fellow Paul E. Beaulé, MD, FRCSC
Department of Orthopaedic Surgery Head, Division of Orthopaedics
Keck School of Medicine Department of Surgery, Division of
Los Angeles, California Orthopaedic Surgery
The Ottawa Hospital
Hussain Al-Yousif, MD Ottawa, Ontario, Canada
Fellow, Surgeon
Department of Orthopaedic Surgery David M. Beck, MD
The Ottawa Hospital, King Saud Medical City Resident
Ottawa, Ontario, Canada Department of Orthopaedic Surgery
Thomas Jefferson University Hospital
Matthew S. Austin, MD Philadelphia, Pennsylvania
Professor
Department of Orthopaedic Surgery Keith R. Berend, MD
Sidney Kimmel Medical College President and CEO
Rothman Institute at Thomas Jefferson White Fence Surgical Suites
University Senior Partner
Philadelphia, Pennsylvania Joint Implant Surgeons
New Albany, Ohio
David C. Ayers, MD
Professor, Arthur M. Pappas Chair Daniel J. Berry, MD
Department of Orthopedics and Physical L.Z. Gund Professor of Orthopedic Surgery
Rehabilitation Department of Orthopedic Surgery
University of Massachusetts Medical School Mayo Clinic
Worchester, Massachusetts Rochester, Minnesota
David Backstein, MD, MEd, FRCSC Mathias P.G. Bostrom, MD

Head, Granovsky Gluskin Division of Professor of Orthopaedic Surgery
Orthopaedics Senior Research Scientist
Mount Sinai Hospital Chief of Hip Service
University of Toronto Department of Orthopaedic Surgery
Toronto, Ontario, Canada Hospital for Special Surgery
New York, New York
© 2017 American Academy of Orthopaedic Surgeons Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 vii
Charles R. Bragdon, PhD John C. Clohisy, MD
Research Scientist Professor
Department of Orthopedics Department of Orthopaedic Surgery
Massachusetts General Hospital Washington University School of Medicine
Boston, Massachusetts St. Louis, Missouri
Justin G. Brothers, MD Benjamin R. Coobs, MD

Fellow Assistant Professor
Department of Orthopaedics Department of Orthopaedic Surgery
University of Utah Virginia Tech Carilion School of Medicine and
Salt Lake City, Utah Research Institute
Roanoke, Virginia
J.W. Thomas Byrd, MD
President and Orthopaedic Surgeon Fred D. Cushner, MD
Nashville Sports Medicine Foundation Chief
Nashville, Tennessee Division of Orthopaedic Surgery at South Side
Hospital
John J. Callaghan, MD Northwell Health
Lawrence and Marilyn Dorr Chair and New York, New York
Professor
Department of Orthopaedics and Rehabilitation Sachin Daivajna, MS, FRCS (Orth)
University of Iowa Fellow
Iowa City, Iowa Department of Adult Reconstructive Surgery
Division of Reconstructive Orthopaedics
Alberto Carli, MD, MSc, FRCSC University of British Columbia
Orthopaedic Surgeon Vancouver, British Columbia, Canada
Division of Orthopaedic Surgery
The Ottawa Hospital Rocco D’Apolito MD
Ottawa, Ontario, Canada Research Fellow
Complex Joint Reconstruction Center
Sasha Carsen, MD, MBA, FRCSC Hospital for Special Surgery
Assistant Professor of Surgery New York, New York
Department of Surgery
Children’s Hospital of Eastern Ontario, The Gregory K. Deirmengian, MD
Ottawa Hospital Associate Professor
University of Ottawa Department of Orthopaedic Surgery
Ottawa, Ontario, Canada Rothman Institute at Thomas Jefferson
University
Morad Chughtai, MD Philadelphia, Pennsylvania
Research Fellow
Department of Orthopaedics Ronald E. Delanois, MD
Rubin Institute for Advanced Orthopaedics Fellowship Director
Baltimore, Maryland Center for Joint Preservation and Replacement
Rubin Institute for Advanced Orthopaedics,
Henry D. Clarke, MD Sinai Hospital of Baltimore
Professor of Orthopedics Baltimore, Maryland
Department of Orthopedic Surgery
Mayo Clinic Craig J. Della Valle, MD
Phoenix, Arizona Orthopaedic Surgeon
Midwest Orthopaedics at Rush
Rush University Medical Center
Chicago, Illinois
viii Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 © 2017 American Academy of Orthopaedic Surgeons
Ivan De Martino, MD Roger H. Emerson, Jr, MD
Fellow Director
Complex Joint Reconstruction Center Joint Replacement Institute
Hospital for Special Surgery Texas Health Plano
New York, New York Texas Health Resources
Plano, Texas
Douglas A. Dennis, MD
Adjunct Professor Jeffrey R. Engorn, DO
Department of Bioengineering Resident
University of Denver Department of Orthopaedic Surgery
Assistant Clinical Professor The Center for Advanced Orthopedics
Department of Orthopaedics Larkin Community Hospital
University of Colorado School of Medicine South Miami, Florida
Denver, Colorado
Thomas K. Fehring, MD
Nicholas M. Desy, MD, FRCSC Co-Director and Surgeon
Clinical Fellow in Adult Lower Extremity OrthoCarolina Hip & Knee Center
Reconstruction Charlotte, North Carolina
Mayo Clinic Tiffany Feltman, DO
Rochester, Minnesota Adult Reconstruction Fellow
Christopher A. Dodd, FRCS Virginia Commonwealth University Health
Consultant Orthopaedic Surgeon System
University of Oxford Richmond, Virginia
Oxford, England
Andrew N. Fleischman, MD
Michael J. Dunbar, MD, FRCSC, PhD Postdoctoral Research Fellow
Professor of Surgery Department of Orthopaedics
Department of Surgery Rothman Institute at Thomas Jefferson
Dalhousie University University
Halifax, Nova Scotia, Canada Philadelphia, Pennsylvania
Clive P. Duncan, MD, MSc, FRCSC Patricia D. Franklin, MD, MBA, MPH
Professor Professor
Department of Orthopaedics Department of Orthopedics and Physical
University of British Columbia Rehabilitation
Vancouver, British Columbia, Canada University of Massachusetts Medical School
Worcester, Massachusetts
John M. Dundon, MD
Fellow Andrew A. Freiberg, MD
Department of Orthopedics, Adult Arthroplasty Service Chief and Vice Chair
Reconstruction Department of Orthopaedic Surgery
New York University Massachusetts General Hospital
New York, New York Boston, Massachusetts
Randa K. Elmallah, MD Rajiv Gandhi, MD, MSc, FRCSC

Orthopaedic Research Fellow Orthopaedic Surgeon, Associate Professor
Rubin Institute for Advanced Orthopaedics Department of Surgery
Sinai Hospital of Baltimore University of Toronto
Baltimore, Maryland University Health Network
Toronto, Ontario, Canada
© 2017 American Academy of Orthopaedic Surgeons Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 ix
Donald Garbuz, MD, FRCSC Allan E. Gross, MD, FRCSC
Professor and Head Order of Ontario
Division of Reconstructive Orthopaedics Orthopaedic Surgeon
University of British Columbia Department of Orthopaedic Surgery
Vancouver, British Columbia, Canada Mount Sinai Hospital
Professor of Surgery
Kevin L. Garvin, MD Department of Surgery
Professor and Chair University of Toronto,
Department of Orthopaedic Surgery and Toronto, Ontario, Canada
Rehabilitation
University of Nebraska Medical Center Steven B. Haas, MD
Omaha, Nebraska Chief Knee Service
Emmanuel Gibon, MD Hospital for Special Surgery
Research Fellow New York, New York
Stanford University Fares S. Haddad, FRCS (Orth)
Stanford, California Professor
Andrew H. Glassman, MD, MS Institute of Sport, Exercise and Health
Professor and Chairman University College London Hospitals
Department of Orthopaedics London, England
The Ohio State University Wexner Medical
Center Mohamad J. Halawi, MD
Columbus, Ohio Adult Reconstructive Surgery Fellow
Gregory J. Golladay, MD Cleveland Clinic
Associate Professor, Fellowship Director, Cleveland, Ohio
Adult Reconstruction
Department of Orthopaedic Surgery Erik Hansen, MD
Virginia Commonwealth University Health Assistant Professor
System Department of Orthopaedic Surgery
Richmond, Virginia University of California
San Francisco, California
Stuart B. Goodman, MD, PhD, FRCSC, FACS
Professor Amir Herman, MD, PhD
Department of Orthopaedic Surgery and Orthopaedic Surgeon
Bioengineering Department of Orthopaedic Surgery
Stanford University Tel-Hashomer Medical Center
Stanford, California Ramat-Gan, Israel
William L. Griffin, MD Shane R. Hess, DO

Orthopedic Surgeon Orthopaedic Surgeon
Department of Orthopedics Department of Adult Reconstruction
OrthoCarolina Hip & Knee Center The CORE Institute
Charlotte, North Carolina Phoenix, Arizona
Daniel J. Holtzman, MD
Fellow
Massachusetts General Hospital
Boston, Massachusetts
x Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 © 2017 American Academy of Orthopaedic Surgeons
James L. Howard, MD, MSc, FRCS(C) Michael M. Kheir, MD
Program Director, Assistant Professor Resident
Division of Orthopaedic Surgery Department of Orthopaedics
Western University, London Health Sciences Indiana University
Centre Indianapolis, Indiana
London, Ontario, Canada
Christopher Kim, MD, MSc
William Hozack, MD Department of Orthopaedic Surgery
Annenberg Professor Toronto Western Hospital
Department of Orthopaedic Surgery Toronto, Ontario, Canada
Rothman Institute at Thomas Jefferson
University Yatin Kirane, MD, PhD
Philadelphia, Pennsylvania Adult Reconstruction Fellow
Stephen J. Incavo, MD Lenox Hill Hospital
Section Chief, Adult Reconstructive Surgery New York, New York
Department of Orthopaedics and Sports
Medicine Viktor E. Krebs, MD
Houston Methodist Hospital Vice Chairman
Houston, Texas Department of Orthopaedic Surgery
Cleveland Clinic
Richard Iorio, MD Cleveland, Ohio
Chief of Adult Reconstruction
Department of Orthopaedic Surgery Steven M. Kurtz, PhD
NYU Langone Medical Center Hospital for Research Professor
Joint Diseases Implant Research Center
New York, New York Drexel University
Philadelphia, Pennsylvania
David J. Jacofsky, MD
Orthopaedic Surgeon Young-Min Kwon, MD, PhD
Department of Adult Reconstruction Fellowship Director, Professor
The CORE Institute Department of Orthopaedic Surgery
Phoenix, Arizona Massachusetts General Hospital
Boston, Massachusetts
William A. Jiranek, MD
Professor Paul F. Lachiewicz, MD
Department of Orthopaedic Surgery Consulting Professor
Virginia Commonwealth University Health Department of Orthopaedic Surgery
System Duke University
Richmond, Virginia Durham, North Carolina
Bryan T. Kelly, MD Kyle W. Lacy, MD, MS

Chief Arthroplasty Fellow
Sports Medicine and Shoulder Service Department of Orthopaedic Surgery
Hospital for Special Surgery Massachusetts General Hospital
New York, New York Boston, Massachusetts
© 2017 American Academy of Orthopaedic Surgeons Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 xi
Jeffery Lange, MD Adolph V. Lombardi, Jr, MD, FACS
Orthopaedic Fellow Clinical Assistant Professor
Department of Orthopaedic Surgery Department of Orthopaedics
Hospital for Special Surgery Joint Implant Surgeons
New York, New York New Albany, Ohio
Carlos J. Lavernia, MD William J. Long, MD, FRCSC

Director Senior Director
The Center for Advanced Orthopaedics Clinical Associate Professor
Larkin Community Hospital NYU Langone Medical Center
South Miami, Florida Insall Scott Kelly Institute
New York, New York
Cameron K. Ledford, MD
Lower Extremity Reconstruction Fellow Jess H. Lonner, MD
Department of Orthopedic Surgery Associate Professor
Mayo Clinic Department of Orthopaedic Surgery
Rochester, Minnesota Sidney Kimmel Medical College
Rothman Institute at Thomas Jefferson
Gwo-Chin Lee, MD University
Associate Professor Philadelphia, Pennsylvania
University of Pennsylvania Steven J. MacDonald, MD, FRCSC
Philadelphia, Pennsylvania Professor, Chairman
Yadin D. Levy, MD University of Western Ontario
Adult Reconstruction and Joint Replacement London, Ontario, Canada
Fellow
Specialist Orthopaedic Group Nizar N. Mahomed, MD, MPH, ScD
Mater Clinic Professor
Sydney, New South Wales, Australia Department of Surgery
Toronto Western Hospital
David G. Lewallen, MD University of Toronto
Professor of Orthopedic Surgery Toronto, Ontario, Canada
Mayo Clinic Arthur L. Malkani, MD
Rochester, Minnesota Chief Adult Reconstruction
Clinical Professor
Guoan Li, PhD Department of Orthopedics
Director, The Bioengineering Laboratory University of Louisville
Department of Orthopaedic Surgery Louisville, Kentucky
Boston, Massachusetts William J. Maloney, MD
Professor and Chairman
Jay R. Lieberman, MD Department of Orthopaedic Surgery
Professor and Chairman Stanford University, School of Medicine
Department of Orthopaedic Surgery Redwood City, California
Keck School of Medicine of University of
Southern California Dean J. Marshall, DO
Los Angeles, California Clinical Fellow
Department of Hip and Knee Reconstruction
Joint Implant Surgeons
New Albany, Ohio
xii Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 © 2017 American Academy of Orthopaedic Surgeons
Bassam A. Masri, MD, FRCSC Bernard F. Morrey, MD
Professor and Chairman Professor of Orthopedic Surgery, Mayo Clinic
Department of Orthopaedics Clinical Professor, Shoulder & Elbow Total
University of British Columbia Joint Arthroplasty, University of Texas Health
Vancouver, British Columbia, Canada Science Center
Department of Orthopedics
James P. McAuley, MD, FRCS(C) Mayo Clinic
Professor Rochester, Minnesota
Department of Orthopaedic Surgery The University of Texas Health Science Center
Western University at San Antonio
London, Ontario, Canada San Antonio, Texas
Richard W. McCalden, MD, MPhil (Edin.), Matthew C. Morrey, MD, MS

FRCS(C) Adjunct Associate Professor
Professor of Surgery Department of Adult Reconstruction and
Western University Orthopedics
Division of Orthopaedic Surgery The University of Texas Health Science Center
London Health Sciences Centre at San Antonio
London, Ontario, Canada San Antonio, Texas
R. Michael Meneghini, MD Orhun K. Muratoglu, PhD

Associate Professor Co-Director, Harris Orthopaedic Lab,
Department of Orthopaedic Surgery Massachusetts General Hospital
Indiana University School of Medicine Professor, Harvard Medical School
Indianapolis, Indiana Department of Orthopaedic Surgery
Harvard Medical School
William M. Mihalko, MD, PhD Boston, Massachusetts
Professor
Campbell Clinic James Nace, DO, MPT
JR Hyde Chair of Excellence in Biomechanical Orthopaedic Surgeon
Engineering Center for Joint Preservation and Replacement
University of Tennessee Health Science Center Rubin Institute for Advanced Orthopaedics,
University of Tennessee Sinai Hospital of Baltimore
Memphis, Tennessee Baltimore, Maryland
Jaydev B. Mistry, MD Abbas Naqvi, MD

Orthopaedic Research Fellow Resident
Center for Joint Preservation and Replacement Department of Orthopaedic Surgery
Rubin Institute for Advanced Orthopaedics, Howard University Hospital
Sinai Hospital of Baltimore Washington, District of Columbia
Baltimore, Maryland
Philip C. Noble, PhD
Michael A. Mont, MD Professor
Chairman Joseph Barnhart Department of Orthopaedic
Department of Orthopaedic Surgery Surgery
Cleveland Clinic Foundation Baylor College of Medicine
Cleveland, Ohio Houston, Texas
© 2017 American Academy of Orthopaedic Surgeons Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 xiii
Andrew B. Old, MD Christopher L. Peters, MD
Fellow Professor
NYU Langone Medical Center University of Utah
New York, New York Salt Lake City, Utah
Ebru Oral, PhD Luis F. Pulido, MD

Assistant Professor Orthopaedic Surgeon
Department of Orthopaedic Surgery Department of Orthopedics and Sports
Massachusetts General Hospital, Harvard Medicine
Medical School Houston Methodist Hospital
Boston, Massachusetts Houston, Texas
Feroz Osmani, BS James J. Purtill, MD

Research Fellow Vice Chairman
Department of Orthopaedic Surgery Department of Orthopaedic Surgery
NYU Langone Medical Center, Hospital for Rothman Institute at Thomas Jefferson
Joint Diseases University
New York, New York Philadelphia, Pennsylvania
Douglas E. Padgett, MD Rohit Rambani, MBBS, MS Ortho, FIMSA,

Chief, Adult Reconstruction and Joint FRCS
Replacement Consultant, Orthopaedics
Hospital for Special Surgery United Lincolnshire Hospital NHS Trust
New York, New York Boston, Lincolnshire, England
Mark W. Pagnano, MD Amar Ranawat, MD

Professor and Chairman Surgeon
Department of Orthopedic Surgery Department of Orthopaedic Surgery
Mayo Clinic Hospital for Special Surgery
Rochester, Minnesota New York, New York
Javad Parvizi, MD, FRCS Anil Ranawat, MD

Professor, Director, Vice Chairman of Research Surgeon
Department of Orthopaedic Surgery Department of Sports Medicine and Joint
Rothman Institute at Thomas Jefferson Preservation
University Hospital for Special Surgery
Philadelphia, Pennsylvania New York, New York
Nirav K. Patel, MD, FRCS Andrew B. Richardson, MD

Clinical Fellow Adult Hip and Knee Reconstruction Fellow
Center for Joint Preservation and Replacement Joint Implant Surgeons
Rubin Institute for Advanced Orthopedics, Sinai New Albany, Ohio
Hospital of Baltimore
Baltimore, Maryland Michael D. Ries, MD
Professor Emeritus
Colin T. Penrose, MD Department of Orthopaedic Surgery
Resident University of California, San Francisco
Department of Orthopaedic Surgery San Francisco, California
Duke University Medical Center
Durham, North Carolina
xiv Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 © 2017 American Academy of Orthopaedic Surgeons
Martin Roche, MD Emil Schemitsch MD, FRCS(C)
Robotics Director Richard Ivey Professor and Chairman
Department of Orthopedic Surgery Department of Surgery
Holy Cross Orthopedic Institute Western University
Fort Lauderdale, Florida London, Ontario, Canada
Harry E. Rubash, MD W. Norman Scott, MD, FACS

Chief of Orthopaedic Surgery Clinical Professor, NYU Langone Medical
Department of Orthopaedic Surgery Center
Massachusetts General Hospital Founding Director, Insall Scott Kelly Institute
Boston, Massachusetts for Orthopaedics and Sports Medicine
Department Orthopaedic Surgery, NYU
Robert Russell, MD Langone Medical Center
Surgeon Department of Orthopaedics and Sports
Department of Orthopedics Medicine, Insall Scott Kelly Institute for
W.B. Carrell Clinic Orthopaedics and Sports Medicine
Dallas, Texas NYU Langone Medical Center Hospital for
Joint Diseases
New York, New York
Christopher Samujh, MD
Staff Surgeon
Department of Orthopedics Giles R. Scuderi, MD
Scranton Orthopaedic Specialists Northwell Health Orthopaedic Institute
Dickson City, Pennsylvania Department of Orthopaedic Surgery
Lenox Hill Hospital
New York, New York
Adam A. Sassoon, MD, MS
Assistant Professor
Department of Orthopaedic Surgery Peter K. Sculco, MD
University of Washington Assistant Attending Orthopaedic Surgeon
Seattle, Washington Department of Adult Reconstruction and Joint
Replacement
Hospital for Special Surgery
Jibanananda Satpathy, MD, MRCSEd New York, New York
Assistant Professor
Department of Adult Reconstruction and
Orthopaedics Thomas P. Sculco, MD
Virginia Commonwealth University Health Attending Orthopaedic Surgeon
System Professor of Orthopaedic Surgery
Richmond, Virginia Department of Orthopaedic Surgery
Hospital for Special Surgery
New York, New York
Siraj A. Sayeed, MD, MEng
President
South Texas Bone and Joint Institute Bryan D. Springer, MD
San Antonio, Texas Fellowship Director
OrthoCarolina Hip & Knee Center
Charlotte, North Carolina
Yousuf Sayeed, MS
Research Fellow
Department of Orthopedics, Adult S. David Stulberg, MD
Reconstruction Clinical Professor, Orthopaedic Surgery
New York University Department of Orthopaedic Surgery
New York, New York Northwestern University, Feinberg School of
Medicine
Chicago, Illinois
© 2017 American Academy of Orthopaedic Surgeons Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 xv
Eric Szczesniak, MD Bradford S. Waddell, MD
Clinical Fellow Fellow
Department of Orthopaedic Surgery, Adult Hip Department of Adult Reconstruction
and Knee Reconstruction Hospital for Special Surgery
Rubin Institute for Advanced Orthopaedics New York, New York
Baltimore, Maryland
William L. Walter, MBBS, PhD
Michael Tanzer, MD, FRCSC Assistant Professor, Orthopaedic Surgeon
Jo Miller Chair and Professor of Surgery Mater Hospital
Division of Orthopaedic Surgery Department of Orthopaedics
McGill University Wollstonecraft, New South Wales, Australia
Montreal, Quebec, Canada
Derek Ward, MD
Savyasachi C. Thakkar, MD Fellow
Adult Reconstruction Surgery Fellow Department of Adult Reconstruction
Department of Orthopaedic Surgery Rothman Institute at Thomas Jefferson
New York University, Hospital for Joint University
Diseases Philadelphia, Pennsylvania
New York, New York
Jennifer S. Wayne, PhD
Gregory A. Tocks, DO Professor
Adult Reconstruction Fellow Department of Biomedical Engineering
Department of Orthopaedic Surgery Virginia Commonwealth University
Virginia Commonwealth University Richmond, Virginia
Richmond, Virginia
Geoffrey Westrich, MD
Robert T. Trousdale, MD Surgeon, Adult Reconstruction and Joint
Professor of Orthopedic Surgery Replacement
Department of Orthopedic Surgery Department of Orthopaedic Surgery
Mayo Clinic Hospital for Special Surgery
Rochester, Minnesota New York, New York
Slif D. Ulrich, MD Geoffrey P. Wilkin, MD, FRCSC

Adult Reconstruction Fellow Assistant Professor
Department of Orthopedics Division of Orthopaedic Surgery
University of Louisville University of Ottawa
Louisville, Kentucky Ottawa, Ontario, Canada
Kartik Mangudi Varadarajan, PhD Joseph L. Yellin, MD

Assistant Director, Technology Implementation Resident
Research Center Harvard Combined Orthopaedic Residency
Department of Orthopaedic Surgery Program
Massachusetts General Hospital Harvard University
Boston, Massachusetts Boston, Massachusetts
Kelly G. Vince, MD, FRCSC

Consultant Surgeon
Northland District Health Board
Whangarei, New Zealand
xvi Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 © 2017 American Academy of Orthopaedic Surgeons
Preface
Orthopaedic Knowledge Update: Hip state-of-the-art technologies. All of the
and Knee Reconstruction 5 comple- chapters have been written by experts
ments and updates information that in each subject, with a concerted effort
was published in the four previous edi- to reflect the current state of hip and
tions. The first edition was published knee reconstruction knowledge with
in 1995, the second in 2000, the third objectivity and a minimal amount of
in 2006, and the fourth in 2011. This personal bias by basing material pri-
edition encompasses a comprehensive marily on evidence-based information
review of the past 5 years of published from these recent reports.
literature on hip and knee arthro-
plasty. This fifth edition serves as an We, the editors, would like to thank
update that can stand on its own. all of the authors for their efforts to
complete their chapters, and putting
This edition should provide residents, up with our relentless constructive
fellows, and practicing orthopaedic criticism. We also gratefully acknowl-
surgeons with a clear understanding of edge the invaluable assistance of
the state-of-the-art knowledge relevant the Publications Department of the
to adult hip and knee reconstruction. American Academy of Orthopaedic
As with the previous four publications, Surgeons. This includes Hans Koelsch,
it can be used as a resource for both PhD, Director; Lisa Claxton Moore,
general orthopaedic surgeons as well Senior Manager, Book Program; Ste-
as hip and knee specialists. ven Kellert, Senior Editor; Courtney
Dunker, Editorial Production Man-
The fifth edition, like the fourth edi- ager; Abram Fassler, Publishing Sys-
tion, is composed of three distinct tems Manager; and Sylvia Orellana,
sections: basic and applied science Publications Assistant. Their work and
relevant to both knee and hip arthro- diligence helped to make this book of
plasty; specific total knee arthroplasty the highest quality.
topics; and specific total hip arthro-
plasty topics. There is updated mate- Michael A. Mont, MD
rial related to controversial topics and Michael Tanzer, MD, FRCSC
© 2017 American Academy of Orthopaedic Surgeons Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 xvii
Table of Contents
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii Chapter 8
Minimally Invasive Surgical Approaches
Section 1: Hip and Knee to Knee Arthroplasty
Giles R. Scuderi, MD; Henry D.
Editors: Michael A Mont, MD and Clarke, MD; Christopher A. Dodd, FRCS . . . . . 95
Chapter 9
Chapter 1 Kinematics in Total Knee Arthroplasty
Imaging of the Hip and Knee for Primary William M. Mihalko, MD, PhD . . . . . . . . . . . . 105
and Revision Arthroplasty
Luis F. Pulido, MD; Stephen J. Incavo, MD . . . . . 3 Chapter 10
Implant Designs of Total Knee
Chapter 2 Arthroplasty
Perioperative Assessment and Kartik Mangudi Varadarajan, PhD;
Management Daniel J. Holtzman, MD; Guoan Li, PhD;
Jay R. Lieberman, MD; Jeffrey Lange, MD; Steven B. Haas, MD;
Ram K. Alluri, MD . . . . . . . . . . . . . . . . . . . . . . 15 Harry E. Rubash, MD;
Andrew A. Freiberg, MD . . . . . . . . . . . . . . . . . 113
Chapter 3
Blood Management Chapter 11
Yatin Kirane, MD, PhD; Special Considerations in Primary Total
Fred D. Cushner, MD . . . . . . . . . . . . . . . . . . . . . 27 Knee Arthroplasty
Andrew B. Old, MD; William J. Long, MD, FRCSC;
Chapter 4 W. Norman Scott, MD, FACS . . . . . . . . . . . . . 131
Osteonecrosis of the Hip and Knee
Nirav K. Patel, MD, FRCS; Jaydev B. Mistry, MD; Chapter 12
Randa K. Elmallah, MD; Morad Chughtai, Bicruciate-Retaining Total Knee
MD; James Nace, DO, MPT; Michael A. Arthroplasty
Mont, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Justin G. Brothers, MD;
Christopher L. Peters, MD . . . . . . . . . . . . . . . . 143
Chapter 5
Economics and Cost Implications of Total Chapter 13
Hip and Total Knee Arthroplasty Unicompartmental, Patellofemoral, and
Richard Iorio, MD; Feroz Osmani, BS; Bicompartmental Knee Arthroplasty
Savyasachi C. Thakkar, MD . . . . . . . . . . . . . . . . 63 Mohamad J. Halawi, MD; Joseph L. Yellin, MD;
Anil Ranawat, MD; Jibanananda Satpathy, MD,
Chapter 6 MRCSEd; Gregory J. Golladay, MD; Jess H. Lonner,
National Joint Registries MD; Wael K. Barsoum, MD . . . . . . . . . . . . . . . 149
Daniel J. Berry, MD; David G. Lewallen, MD;
Fares S. Haddad, FRCS (Orth) . . . . . . . . . . . . . . 73 Chapter 14
Robotic-Assisted Knee Arthroplasty
Martin Roche, MD . . . . . . . . . . . . . . . . . . . . . 163
Section 2: Knee
Editor: Michael A. Mont, MD Chapter 15
Computer-Assisted Knee Arthroplasty
Chapter 7 S. David Stulberg, MD; Michael Dunbar, MD,
Biomechanics of the Knee FRCSC, PhD; Gwo-Chin Lee, MD . . . . . . . . . . 173
Gregory A. Tocks, DO; William A. Jiranek, MD;
Jibanananda Satpathy, MD, MRCSEd; Chapter 16
Jennifer S. Wayne, PhD . . . . . . . . . . . . . . . . . . . 85 The Difficult Primary Total Knee
Arthroplasty
Jaydev B. Mistry, MD; Siraj A. Sayeed, MD,
MEng; Morad Chughtai, MD;
Randa K. Elmallah, MD; Michael A. Mont, MD;
Ronald E. Delanois, MD . . . . . . . . . . . . . . . . . 183
© 2017 American Academy of Orthopaedic Surgeons Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 xix
Chapter 17
Section 3: Hip
Management of Extra-Articular
Deformities in Knee Arthroplasty Editor: Michael Tanzer, MD, FRCSC
Abbas Naqvi, MD; Jaydev B. Mistry, MD;
Randa K. Elmallah, MD; Morad Chughtai, MD; Chapter 25
Michael A. Mont, MD . . . . . . . . . . . . . . . . . . . 197 Arthroplasty Management of Hip
Fractures: Hemiarthroplasty Versus
Chapter 18 Total Hip Arthroplasty—Results and
Outcomes of Primary Total Knee Complications
Arthroplasty Michael Tanzer, MD, FRCSC . . . . . . . . . . . . . . 313
David C. Ayers, MD; Patricia D. Franklin, MD,
MBA, MPH; Rajiv Gandhi, MS, MD, FRCSC; Chapter 26
Christopher Kim, MD, MSc; Jeffrey Lange, MD;
Nizar N. Mahomed, MD, MPH, ScD; Nonarthroplasty Joint-Preserving Surgery
Philip C. Noble, PhD . . . . . . . . . . . . . . . . . . . . 207 for Hip Disorders
Paul E. Beaulé, MD, FRCSC; J.W. Thomas Byrd,
Chapter 19 MD; Geoffrey P. Wilkin, MD, FRCSC;
Bryan T. Kelly, MD; Sasha Carsen, MD, MBA,
Outpatient Total Knee Arthroplasty FRCSC; Hussain Al-Yousif, MD; Benjamin R.
Adolph V. Lombardi, Jr, MD, FACS; Coobs, MD; John C. Clohisy, MD . . . . . . . . . . 321
Dean J. Marshall, DO . . . . . . . . . . . . . . . . . . . 223
Chapter 27
Chapter 20 Alternatives to Conventional Total Hip
Complications of Knee Arthroplasty Arthroplasty for Osteoarthritis
Viktor E. Krebs, MD; Arthur L. Malkani, MD; Adam A. Sassoon, MD, MS; William J. Maloney,
Slif D. Ulrich, MD; David Backstein, MD, MEd, MD; John C. Clohisy, MD . . . . . . . . . . . . . . . . 339
FRCSC; Mansour Abolghasemian, MD;
Bryan D. Springer, MD;
Christopher Samujh, MD . . . . . . . . . . . . . . . . . 233 Chapter 28
Surgical Approaches and Bearing Surfaces
Chapter 21 William Hozack, MD; Clive P. Duncan, MD, MSc,
Revision Total Knee Arthroplasty FRCSC; Amir Herman, MD, PhD; Erik Hansen,
MD; Mark W. Pagnano, MD; James L. Howard,
R. Michael Meneghini, MD; Kelly G. Vince, MD, MD, MSc, FRCS(C); James P. McAuley, MD,
FRCSC; Bradford S. Waddell, MD; FRCS(C); William A. Jiranek, MD; Tiffany Feltman,
Geoffrey Westrich, MD . . . . . . . . . . . . . . . . . . 267 DO; Orhun K. Muratoglu, PhD; Ebru Oral, PhD;
Gregory K. Deirmengian, MD; William L. Wal-
Chapter 22 ter, MBBS, PhD; Yadin D. Levy, MD; Richard W.
Perioperative Pain Management in Knee McCalden, MD, MPhil (Edin.), FRCS(C); Emil
Arthroplasty Schemitsch, MD, FRCS(C) . . . . . . . . . . . . . . . . 345
Colin T. Penrose, MD;
John W. Barrington, MD . . . . . . . . . . . . . . . . . 279 Chapter 29
The Biologic Response to Bearing
Chapter 23 Materials
Retrieval Analysis of Knee Prostheses Emmanuel Gibon, MD; Stuart B.
Steven M. Kurtz, PhD; Jaydev B. Mistry, MD; Goodman, MD, PhD, FRCSC, FACS . . . . . . . . 367
Eric Szczesniak, MD; Randa K. Elmallah, MD;
Morad Chughtai, MD; Chapter 30
Michael A. Mont, MD . . . . . . . . . . . . . . . . . . . 291 Primary Total Hip Arthroplasty
Craig J. Della Valle, MD; Daniel J. Berry, MD;
Chapter 24 Charles R. Bragdon, PhD; John J. Callaghan, MD;
Nonarthroplasty Management of Knee Rocco D’Apolito, MD; Douglas A. Dennis, MD;
Arthritis Ivan De Martino, MD; Roger H. Emerson, Jr, MD;
Andrew A. Freiberg, MD; Young-Min Kwon, MD,
David J. Jacofsky, MD; PhD; Kyle W. Lacy, MD, MS; Steven J. MacDonald,
Shane R. Hess, DO . . . . . . . . . . . . . . . . . . . . . . 299 MD, FRCSC; R. Michael Meneghini, MD; Matthew
C. Morrey, MD, MS; Bernard F. Morrey, MD; Amar
Ranawat, MD; Harry E. Rubash, MD;
Thomas P. Sculco, MD . . . . . . . . . . . . . . . . . . . 377
xx Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 © 2017 American Academy of Orthopaedic Surgeons
Chapter 31 Chapter 35
Primary Total Hip Arthroplasty in Chal- Complications of Total Hip Arthroplasty
lenging Conditions Michael M. Kheir, MD; Javad Parvizi, MD, FRCS;
Andrew H. Glassman, MD, MS; Michael Tanzer, Andrew N. Fleischman, MD;
MD, FRCSC; Richard Iorio, MD; Anthony Albers, MDCM, FRCSC;
John M. Dundon, MD; Yousuf Sayeed, MS; Mathias Clive P. Duncan, MD, MSc, FRCSC;
P.G. Bostrom, MD; Michael D. Ries, MD; Bassam A. Masri, MD, FRCSC; Derek Ward, MD;
Robert T. Trousdale, MD; Keith R. Berend, MD; Matthew S. Austin, MD;
Nicholas M. Desy, MD, FRCSC . . . . . . . . . . . . 393 Peter K. Sculco, MD; Thomas K. Fehring, MD;
David M. Beck, MD; James J. Purtill, MD;
Jeffrey R. Engorn, DO;
Chapter 32 Carlos J. Lavernia, MD . . . . . . . . . . . . . . . . . . 473
Computer Navigation and Robotics in
Total Hip Arthroplasty Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 507
Bradford S. Waddell, MD;
Douglas E. Padgett, MD . . . . . . . . . . . . . . . . . . 423
Chapter 33
Rapid Recovery in Total Hip Arthroplasty
Adolph V. Lombardi, Jr, MD, FACS; Andrew B.
Richardson, MD; Kevin L. Garvin, MD . . . . . . 437
Chapter 34
Revision Total Hip Arthroplasty
Anthony Albers, MD, FRCSC; Alberto Carli, MD,
MSc, FRCSC; Sachin Daivajna, MS, FRCS (Orth);
William L. Griffin, MD; Robert Russell, MD;
Allan E. Gross, MD, FRCSC;
Paul F. Lachiewicz, MD; Cameron K. Ledford, MD;
David G. Lewallen, MD; Douglas E. Padgett, MD;
Rohit Rambani, MBBS, MS Ortho, FIMSA, FRCS,
Tr & Orth; Donald Garbuz, MD, FRCSC . . . . 453
© 2017 American Academy of Orthopaedic Surgeons Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 xxi
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Chapter 1
Imaging of the Hip and Knee for

Primary and Revision Arthroplasty
Luis F. Pulido, MD Stephen J. Incavo, MD
Abstract Introduction
1: Hip and Knee

The myriad diagnostic imaging modalities currently The myriad diagnostic imaging modalities available are
available are important tools for the diagnosis and important tools for the diagnosis and management of
treatment of patients with musculoskeletal disorders, musculoskeletal disorders, including for patients under-
including patients undergoing hip and knee arthroplasty. going hip and knee arthroplasty. Picture archiving and
The digitization of radiographs with picture archiving communication systems have improved the storage of and
and communication systems has improved the storage access to digitized radiography. Plain radiographs are used
of and access to medical images. Plain radiographs are as the first-line diagnostic test in orthopaedics. A method-
the first-line diagnostic test in orthopaedics. A methodic ic approach to the evaluation of hip and knee radiographs
approach to the evaluation of hip and knee radiographs is is usually sufficient to determine a diagnosis and establish
usually sufficient to determine a diagnosis and establish a treatment plan. The accuracy and efficiency of total hip
a treatment plan. Preoperative planning using digital arthroplasty (THA) and total knee arthroplasty (TKA)
templating of calibrated radiographs aids the accuracy is increased using digital templates of calibrated radio-
and efficiency of total hip and total knee arthroplasty. graphs. Recent advances in other imaging techniques such
Recent advances in other imaging techniques such as as low-dose radiation imaging systems, nuclear medicine,
low-dose radiation systems, nuclear medicine, ultra- ultrasonography, CT, and MRI have a complementary
sonography, CT, and MRI have a complementary role role in the clinical evaluation patients before and after hip
in the evaluation of different clinical scenarios before and knee arthroplasty. The use of digital radiographs is
and after hip and knee arthroplasty. important in the evaluation and preoperative planning of
primary and revision THA and TKA. The advances and
clinical usefulness of newer diagnostic imaging tests are
Keywords: hip arthroplasty; knee arthroplasty; discussed, including the supplementary role of modern nu-
diagnostic imaging in arthroplasty; nuclear clear medicine in the evaluation of the painful total joint
medicine; digital radiographs in arthroplasty arthroplasty and the use of ultrasonography in patients
with hip disorders or in whom hip arthroplasty was un-
successful. In addition, the role of advanced imaging such
as CT in the evaluation of implant position, osteolysis,
and bone loss after hip and knee arthroplasty, as well as
Dr. Incavo or an immediate family member has received the use of modern MRI modalities in the evaluation of
royalties from Biomet, Innomed, Smith & Nephew, Wright hip and knee osteochondral lesions and periprosthetic
Medical Technology, and Zimmer, serves as a paid consultant soft-tissue injuries or adverse soft-tissue reactions are also
to Zimmer, has stock or stock options held in Zimmer, and reviewed. Radiographs are the initial diagnostic test used
serves as a board member, owner, officer, or committee for the evaluation of patients with hip and knee problems.
member of the Knee Society. Neither Dr. Pulido nor any Weight-bearing views provide a more reliable evaluation
immediate family member has received anything of value of limb alignment and joint space narrowing in patients
from or has stock or stock options held in a commercial with hip and knee osteoarthritis.
company or institution related directly or indirectly to the
subject of this chapter.
© 2017 American Academy of Orthopaedic Surgeons Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 3
Section 1: Hip and Knee
Preoperative Planning and Digital Templating

Digital templating is an important tool in planning pri-
mary and revision THA.1 Digital implant template overlay
helps determine the best implant fit, size, and position
with the goal of restoring hip biomechanics. Restoration
of the normal center of rotation, the femoral lateral offset,
and leg lengths are important goals to achieve in the pre-
operative planning and execution of THA. A methodical,
stepwise approach for templating THA is described in
Figure 1.
Hip Dysplasia
Preoperative planning for THA in patients with end-stage
hip disease resulting from hip dysplasia has unique ace-
tabular and femoral anatomic features. Plain radiographs
1: Hip and Knee
Figure 1 Weight-bearing AP pelvic radiograph with are sufficient for surgical planning and digital templating.
lower extremities in 10 to 15° of internal The dysplastic acetabulum is small, shallow, steep, and
rotation demonstrates stepwise approach for
templating total hip arthroplasty. (1) Digital
elongated.2 The cup should ideally be placed at the hip’s
image is calibrated with markers. (2) Pelvic true center of rotation. Femoral head autograft can be
axis orientation is determined using a line used to reconstitute large superolateral acetabular defects.
(long orange) across the teardrops. (3) Leg
lengths are determined using the distance The use of a high hip center is less favorable because
from a line (short orange) perpendicular to the of abnormal hip biomechanics, increased joint reaction
pelvic axis and the tops of the lesser or greater forces, and increased risk of failure. The dysplastic femur
trochanters. (4) The acetabular component
(blue outline) is placed to restore the hip center has a high femoral neck-shaft angle with increased fem-
of rotation with the cup apex just lateral to the oral anteversion. The use of a femoral stem that allows
teardrop at 40° to 45° of abduction from the
pelvic axis. (5) The femoral component (blue adjustment of femoral version is preferable.3 This can be
outline) is templated to determine the best accomplished with a cemented or modular noncemented
fitting stem and stem sizes to restore femoral stem. A subtrochanteric shortening osteotomy is useful
lateral offset and equalize leg lengths.
for the management of hip dysplasia with high-grade dis-
location to avoid iatrogenic stretch injury to the peroneal-
sciatic nerve4 (Figure 2).
Total Hip Arthroplasty
Femoral Deformity
Standard views for the evaluation of hip disorders in- Biplanar radiographs with magnification markers of the
clude a weight-bearing AP view of the pelvis and AP and pelvis and entire femur are recommended in the surgical
cross-table lateral views of the hip. The proper technique planning of THA in patients with proximal femoral defor-
to obtain a pelvic AP view for accurate determination of mity. Digital templating helps plan the management of
neck length and femoral lateral offset includes direct- different deformity sites (greater trochanter, femoral neck,
ing the x-ray beam perpendicularly and centered on a metaphysis, and diaphysis) and types (angular, transla-
midpoint between the symphysis pubis and the anterior tional, and torsional). The use of modular stems with
superior iliac spine with the lower extremities in 10° to distal stability or fixation may become more important
15° of internal rotation. The cross-table lateral radiograph in this clinical scenario.
is obtained with the patient supine, the contralateral hip
flexed, and the affected limb in 15° of internal rotation Pelvic Obliquity
and the x-ray beam oriented at 45° to the affected hip. The pelvic axis orientation is corrected during preop-
Other hip radiographic views such as the frog-leg lateral, erative templating and surgical completion of THA for
Dunn views, and false profile views are recommended in accurate acetabular abduction angle placement and leg
the evaluation of the young adult (age 15 to 45 years) with length equalization. In most cases, restoration of the
hip pain resulting from femoroacetabular impingement coronal balance of the pelvis following THA is associ-
and hip dysplasia. Judet views are supplemental in the ated with compensation of the coronal alignment of the
evaluation of pelvic bone loss and column integrity in spine. As a result, spinal imbalance and back pain can
acetabular revision. worsen in some patients with rigid degenerative scoliosis
4 Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 © 2017 American Academy of Orthopaedic Surgeons
Chapter 1: Imaging of the Hip and Knee for Primary and Revision Arthroplasty
1: Hip and Knee

Figure 2 A, Preoperative AP pelvic radiograph in a young patient with hip dysplasia and high-grade dislocation (Crowe-
Ranawat stage IV). B, Postoperative AP pelvic radiograph obtained following complex noncemented total hip
arthroplasty. The noncemented acetabular implant was placed to restore the hip center of rotation.
following THA.5 Weight-bearing radiographs obtained and fractures. Preoperative templating is also an impor-
using a block on the shortened leg can help determine tant aspect of revision THA.
the target for any planned leg lengthening. Any pelvic
obliquity resulting from rigid scoliosis, if corrected, will Implants
result in spinal imbalance and should be avoided. Plain radiographs are used to determine the type of fem-
oral and acetabular implants as well as bearing surfaces.
Pelvic Tilt The poor performance of certain hip implants warns
Lumbopelvic lordosis and kyphosis present a challenge in about specific causes and mechanisms of failure after
THA because pelvic tilt determines functional anteversion THA. Weight-bearing AP pelvic and cross-table lateral
and inclination of the acetabulum. Sagittal lumbopelvic views are used to evaluate acetabular and femoral com-
plane deformities can be rigid or flexible. Pelvic tilt varies ponent malposition. The etiology of hip instability is mul-
during simple activities such as standing, sitting, or lying tifactorial, and problems such as lack of femoral offset,
down, which makes functional acetabular position a diffi- excessive acetabular inclination, and version abnormali-
cult, mobile target when considered in the setting of THA. ties can be seen on plain radiographs. Iliopsoas impinge-
Recently, interest has been generated in adjustment of the ment resulting from retroverted acetabular components
acetabular component position based on the functional with prominent, uncovered metal anteriorly results in a
pelvic tilt seen on weight-bearing radiographs.6 painful hip following arthroplasty and is easily evaluated
using the cross-table lateral view. Sequential radiographic
evaluation can be extremely helpful to determine femoral
Revision THA and acetabular fixation with and without cement.
The key principle in revision surgery is understanding the
cause of failure and determining a successful treatment Osteolysis and Bone Loss
plan. The most common causes of failure after hip ar- Plain radiographic findings tend to underestimate peri-
throplasty include aseptic loosening, instability, osteolytic prosthetic osteolysis and bone loss. However, in the set-
wear, periprosthetic fractures, and deep infection.7 Plain ting of mechanical failure and migration of the acetabular
radiographs allow evaluation of the type of prosthesis, component, AP pelvic, cross-table lateral, and Judet views
implant position, fixation, wear, periprosthetic bone loss, can help assess major segmental bone defects and the
knee anatomic and mechanical axes. These images also

provide evidence of possible hip disorders, which must
be ruled out in all painful knees, and help identify any
deformities of the femur and/or tibia. The axial alignment
of the knee seen in two-dimensional (2D) frontal views
is influenced by the lower extremity rotation. Excessive
internal rotation simulates valgus alignment, and exces-
sive external rotation simulates varus alignment.10 A 30°
weight-bearing flexion view helps to more accurately de-
termine joint space narrowing in the native knee.
In primary TKA, digital templates allow assessment
of a deformity and help plan the correction using femoral
and tibial bone cuts to restore mechanical axis. Digital
templating also allows determination of the femoral im-
plant size to restore posterior condylar offset and avoid
1: Hip and Knee
notching.
A stepwise approach for templating TKA should be fol-
Figure 3 AP radiographs of the left hip of a 64-year-old
man who had undergone femoral revision for lowed. First, the digital image is calibrated with markers.
periprosthetic femur fracture complicated by For the lateral view, the size of the femoral implant on the
a deep prosthetic joint infection and a chronic lateral view to restore posterior condylar offset and avoid
draining sinus. A, Preoperative view used to
plan length and type of osteotomy to remove anterior notching should be established. Next, sagittal
a well-fixed noncemented modular titanium femoral bowing, patellar height, and tibial slope should
stem. B, Postoperative view obtained following
posterior extended trochanteric osteotomy, be assessed. For the AP view (long leg or short knee),
removal of hip implants, placement of high- the mechanical axis should be determined on AP view.
dose antibiotic cement dynamic spacer, and Distal femoral and proximal tibia resection angles should
extended trochanteric osteotomy reduction
with wires. be planned to restore the mechanical axis, depending on
the surgeon’s preferred technique. Long leg radiographs
are important to obtain in patients with extra-articular
deformity (Figure 4).
presence of pelvic discontinuity.8 The evaluation of fem-
oral diaphyseal bone loss on radiographs is important
in preoperative planning to help define the method used Revision TKA
for femoral revision. The quality and length of the isth- Aseptic loosening, instability, malalignment, and peri-
mus is evaluated because distally fixed tapered modular prosthetic joint infection are the most common causes of
fluted titanium stems have been universally adopted in failure after TKA.11 Plain radiographs are used to help
femoral revision because of superior clinical results and determine the cause of failure, for surveillance, and for
versatility.9 surgical planning.
Extended Trochanteric Osteotomy Implant Position

Plain radiographs are needed to determine the need for, The knee implant position can be determined using the
type, and length of a femoral osteotomy. An extended standard knee series views noted previously. Neutral,
trochanteric osteotomy is important to facilitate implant varus, or valgus alignment of the femur and tibia is
removal, cement removal, and femoral revision (Figure 3). determined using coronal AP views. The lateral knee
radiographs help determine the amount of tibial slope,
posterior femoral offset, and sagittal position of the fem-
Total Knee Arthroplasty oral implant. In revision TKA for flexion instability or in
The standard knee radiographic series includes a patients with flexion contracture, the distance from the
weight-bearing AP view obtained with neutral rotation medial epicondyle to the femoral joint line is measured
of the limbs, a lateral view with the knee flexed 30°, and to determine if the femoral component is too distal. The
a Merchant axial view. The advantage of a full-length posterior femoral offset and tibial slope are also measured
weight-bearing AP view of the lower extremity over short- on the lateral radiographs and corrected in revision sur-
er images is that it allows more precise measurement of gery for flexion instability.12
Figure 4 Lateral (A) and full-length bilateral AP weight-bearing (B) radiographs demonstrate right knee degenerative joint
disease with associated right femoral extra-articular deformity. AP (C) and lateral (D) radiographs of the right knee
demonstrate successful simultaneous total knee arthroplasty and deformity correction with femoral osteotomy
1: Hip and Knee

and retrograde nail fixation.
Implant Fixation models of the spine, pelvis, and lower limbs.13,14 In THA,
Standard knee views, sequential radiographs, and occa- the EOS system can be used to accurately determine the
sionally, fluoroscopic views, can help determine femoral acetabular position. However, this system is limited when
and tibial loosening after TKA. The size, percentage, used in the evaluation of periprosthetic loosening and
and location of radiolucent lines help determine loosen- osteolysis. The potential role for the EOS system in THA
ing. Technologies such as radiostereometric analysis are includes the evaluation and planning of the functional
more accurate to measure implant migration after TKA. position of the acetabulum relative to the lumbopelvic
Radiostereometric analysis has limited clinical use and changes during standing and sitting positions.14,15
is mainly used for clinical research.
Multidetector CT
Multidetector CT is superior to plain radiography and
Advanced Imaging Techniques can be used as a supplementary diagnostic test to help
Digital Radiographic Imaging Systems diagnose prearthritic conditions of the hip as well as hip
New and advanced imaging technologies such as the EOS and knee implant fixation, loosening, position, and peri-
imaging system (EOS Imaging) provides functional radio- prosthetic bone loss. Multidetector CT has improved effi-
graphic information in different positions such as stand- ciency and imaging quality compared with conventional
ing, squatting, and sitting. The role of low-dose radiation CT. Narrower collimation and low pitch adjustments in
imaging in THA has not been established; however, 2D multidetector CT reduces metal artifacts and improves
and three-dimensional (3D) functional images obtained the image quality of bone and soft tissues around hip and
with low-dose radiation imaging are important in de- knee implants.16
termining the hip-spine relationship in THA. The EOS The evaluation and planning of hip preservation sur-
imaging system is capable of providing weight-bearing gery in patients with hip dysplasia and femoroacetabular
biplanar digital radiographs and 3D reconstructions of impingement (FAI) can be supplemented using CT (Fig-
the entire body. The EOS imaging system consists of two ure 6). In addition, CT can be used in hip preservation to
pairs of perpendicularly positioned, vertically moving, evaluate the patient’s femoral version and torsion. Patients
linked units of x-ray tubes that produce thin collimated with hip osteoarthritis secondary to severe hip dysplasia
x-ray beams collected by the detectors, resulting in si- have small, elongated acetabula and excessive femoral
multaneous, spatially calibrated weight-bearing AP and anteversion, which can be determined with a preoperative
lateral images. Static functional views in standing, sitting, CT scan.2
or squatting positions (Figure 5) can be obtained in 10 to CT can be used in the evaluation of patients with
25 seconds with a fraction of the radiation used with plain painful THAs and equivocal radiographic findings. CT
radiographs (sixfold to ninefold reduction in radiation) is more accurate than radiography for the evaluation of
or CT (600-fold reduction in radiation). implant position and fixation. CT is used to evaluate im-
The EOS system also can create 3D reconstruction plant position in patients with hip instability or anterior
1: Hip and Knee
Figure 5 Biplanar digital AP (A, C, E) and lateral (B, D, F) radiographs obtained using the EOS (EOS Imaging) low-dose
radiation imaging system in weight-bearing (A, B), sitting (C, D), and squatting (E, F) positions. (Copyright Jean
Yves Lazennec, MD, PhD, Paris, France.)
Figure 6 Images from a 17-year-old girl with symptomatic mild hip dysplasia whose nonsurgical treatment was unsuccessful.
A and B, Preoperative AP radiographs. C, CT scan with three-dimensional reconstruction confirms the lack
of anterior and lateral coverage of the femoral head. E and F, Postoperative radiographs obtained following
successful periacetabular osteotomy demonstrate improved anterior and lateral coverage.
hip pain secondary to iliopsoas impingement (Figure 7). In of the periacetabular osteolysis and vascular anatomy
addition, periacetabular osteolysis is more accurately de- are helpful when complex acetabular revision surgery is
termined with CT than plain radiography: CT facilitates considered.
for better detection, characterization, and quantification Rotational malalignment of the femur and/or tibia can
of bone loss around acetabular and femoral implants, as be the cause of knee pain, patella maltracking, stiffness,
well as more accurate determination of implant fixation.17 or instability after TKA. 2D axial CT scans have weak
CT scans have limited use for the evaluation of peri- interobserver and intraobserver reliability in determining
articular masses and fluid collections following THA. In the rotation of the tibial and femoral implants relative to
patients whose metal-on-metal hip arthroplasties were bony landmarks.19 3D reconstruction images are superior
unsuccessful, the sensitivity for diagnosising pseudotu- and more reliable in obtaining rotational measurements
mors is only 44%.17 In this setting, the use of MRI with of TKA components.20
metal suppression or ultrasonography is recommended.
Preoperative CT angiography with 3D reconstruction Magnetic Resonance Imaging
can help with surgical planning and awareness of abnor- MRI is used routinely in the evaluation of the young
mal vascular anatomy around the acetabulum.18 Details adult with hip pain. Metal artifact reduction sequence
1: Hip and Knee

Figure 7 Images of a patient with persistent anterior groin pain following noncemented total hip arthroplasty. AP (A)
and cross-table lateral (B) views demonstrate no radiographic evidence of retroversion. Axial (C) and sagittal (D)
CT scans demonstrate a noncemented acetabular implant with a prominent anterior rim. Postoperative AP (E)
and cross-table lateral (F) radiographs obtained following acetabular revision to treat iliopsoas impingement.
(Copyright Rafael J. Sierra, MD, Mayo Clinic, Rochester, MN.)
MRI (MARS MRI) has the capability to produce high- layers in healthy articular cartilage. Cartilage damage
resolution images of periprosthetic tissues in patients with shows an increased amount of free water and increased
THA implants.21 MARS MRI is commonly used for pa- T2-signal intensity (Figure 8).
tients with metal-on-metal bearing surfaces, modular T1ρ mapping measures low-frequency interactions be-
neck prostheses, or in cases for which concern exists for tween hydrogen and the macromolecules in free water.
adverse soft-tissue reaction following THA. T1ρ values are correlated with the hyaline cartilage pro-
Magnetic resonance arthrography has been the pre- teoglycan content. T1ρ values increase as proteoglycan
ferred imaging test in the evaluation of FAI and associated content decreases in articular cartilage.22
labral pathology. However, modern 3-T MRI provides The dGEMRIC technique uses a negatively charged
high-quality hip images, including osseous and soft-tissue gadolinium-based contrast agent to measure the gly-
structures. The labrum can be well visualized without cosaminoglycan content of the cartilage. The loss of
using intra-articular contrast injection. Other advances in glycosaminoglycan in cartilage is an early biochemical
MRI include the use of biochemical imaging techniques change that precedes structural damage. The recent use
such as T2 mapping, T1 rho (T1ρ) imaging, and delayed of dGEMRIC imaging in the evaluation of hip cartilage
gadolinium-enhanced MRI of cartilage (dGEMRIC). has demonstrated a correlation of low dGEMRIC index
These techniques were developed to detect cartilage bio- and hip pain in patients with underlying hip dysplasia
chemical changes, which precede structural damage or and FAI.23 A low dGEMRIC index is also associated
degeneration, and are used in the evaluation of patients with poor early outcomes in hip preservation surgery for
with hip dysplasia or FAI.22 hip dysplasia.24
T2 mapping measures the changing interactions be- MARS MRI is used in patients with THA implants for
tween water and collagen molecules of the cartilage, better visualization of periprosthetic bone and soft-tissue
including the zonal variations in articular cartilage. structures. MARS MRI is recommended when suspi-
T2 mapping values increase from deep to transitional cion exists for corrosion-related metal-adverse soft-tissue
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CHAPTER IV
SPACE AND TIME

§ 1. Are time and space ultimately real or only phenomenal? § 2. The space and
time of perception are limited, sensibly continuous, and consist of a
quantitative element together with a qualitative character dependent on
relation to the here and now of immediate individual feeling. § 3. Conceptual
space and time are created from the perceptual data by a combined process
of synthesis, analysis, and abstraction. § 4. They are unlimited, infinitely
divisible, and there is valid positive ground for regarding them as
mathematically continuous. Thus they form infinite continuous series of
positions. They involve abstraction from all reference to the here and now of
immediate feeling, and are thus homogeneous, i.e. the positions in them are
indistinguishable. They are also commonly taken to be unities. § 5. Perceptual
space and time cannot be ultimately real, because they involve reference to
the here and now of a finite experience; conceptual space and time cannot be
ultimately real, because they contain no principle of internal distinction, and
are thus not individual. § 6. The attempt to take space and time as real leads
to the difficulty about qualities and relations, and so to the indefinite regress. §
7. Space and time contain no principle of unity; there may be many space and
time orders in the Absolute which have no spatial or temporal connection with
each other. § 8. The antinomies of the infinite divisibility and extent of space
and time arise from the indefinite regress involved in the scheme of qualities
and relations, and are insoluble so long as the space and time construction is
taken for Reality. § 9. The space and time order is an imperfect phenomenal
manifestation of the logical relation between the inner purposive lives of finite
individuals. Time is an inevitable aspect of finite experience. How space and
time are transcended in the Absolute experience we cannot say.
§ 1. The problems which arise for the metaphysician from the fact
that the physical order, as it is presented to our senses, consists of
elements having position in space and time, are among the oldest
and most perplexing of all the riddles suggested by the course of our
experience. Adequate discussion of them would demand not only far
more space than we are at liberty to bestow on the topic, but such a
familiarity with the mathematical theory of order and series as is
scarcely possible to any one but an original mathematician. All that
we can do in the present chapter is to deal very superficially with one
or two of the leading problems, more with a view to indicating the
nature of the questions which Metaphysics has to face, than of
providing definite answers to them.
The fundamental problem for Metaphysics is, of course, whether
space and time are ultimate Realities or only appearances; that is,
would the whole system of Reality, as directly apprehended by an
absolute all-containing experience, wear the forms of extension and
succession in time, or is it merely a consequence of the limitations of
our own finite experience that things come to us in this guise? It may
indeed be urged that the contents of the universe must form an order
of some sort for the absolute experience, in virtue of their systematic
unity, but even so it is not clear that order as such is necessarily
spatial or temporal. Indeed, most of the forms of order with which we
are acquainted, both in everyday life and in our mathematical
studies, appear to be, properly speaking, both non-spatial and non-
temporal. Thus, e.g., it is seemingly by a mere metaphor that we
speak of the “successive” integers of the natural number-series, the
“successive” powers of an algebraical symbol, the “successive”
approximations to the value of a continued fraction, in language
borrowed from the temporal flow of events, the true relation involved
being in the first two cases the non-temporal one of logical
derivation, and in the third the equally non-temporal one of
resemblance to an ideal standard. The full solution of the
metaphysical problem of space and time would thus involve (1) the
discrimination of spatial and temporal order from other allied forms of
order, and (2) a decision as to the claim of this special form of order
to be ultimately coherent and intelligible.
The problem thus presented for solution is often, and usually with
special reference to the Kantian treatment of space and time in the
Transcendental Æsthetic, put in the form of the question whether
space and time are subjective or objective. This is, however, at best
a misleading and unfortunate mode of expression which we shall do
well to avoid. The whole distinction between a subjective and an
objective factor in experience loses most of its significance with the
abolition, now effected by Psychology, of the vicious Kantian
distinction between the “given” in perception and the “work of the
mind.” When once we have recognised that the “given” itself is
constituted by the movement of selective attention, it becomes
impossible any longer to distinguish it as an objective factor in
knowledge from the subjective structure subsequently raised upon it.
Kant’s adherence to this false psychological antithesis so completely
distorts his whole treatment of the “forms of intuition,” that it will be
absolutely necessary in a brief discussion like our own to deal with
the subject in entire independence of the doctrines of the Æsthetic,
which unfortunately continue to exercise a disproportionate influence
on the current metaphysical presentment of the problem.[141] It should
scarcely be necessary to point out that the metaphysical questions
have still less to do with the psychological problems, so prominent in
recent science, of the precise way in which we come by our
perception of extension and succession. For Metaphysics the sole
question is one not of the origin but of the logical value of these
ideas.
It is of fundamental importance for the whole metaphysical
treatment of the subject, to begin by distinguishing clearly between
space and time as forms of perception, and space and time as
conceptual forms in which we construct our scientific notion of the
physical order. One chief source of the confusions which beset the
Kantian view is the neglect of Kant and most of his followers to make
this distinction with sufficient clearness. We cannot insist too strongly
upon the point that the space and the time of which we think in our
science as containing the entire physical order, are not space and
time as directly known to us in sense-perception, but are concepts
elaborated out of the space and time of direct perception by a
complicated process of synthesis and analysis, and involving
abstraction from some of the most essential features of the space
and time of actual experience. The following brief discussion may
serve to illustrate the general nature of the relation between the two
forms of space and time, and to exhibit the leading differences
between them.
§ 2. Perceptual Space and Time. Both space and time, as we are
aware of them in immediate perception, are (1) limited. The space
we actually behold as we look out before us with a resting eye is
always terminated by a horizon which has a more or less well-
defined outline; the “specious present,” or portion of duration of
which we can be at any time aware at once as an immediately
presented content, has been shown by elaborate psychological
experimentation to have a fairly well-defined span. Whatever lies
outside this “span of attention” belongs either to the no longer
presented past or to the not yet presented future, and stands to the
sensible present much as the space behind my back to the actually
beheld space before my eyes. Of course, in either case the limits of
the actually presented space or time are not absolutely defined. To
right and left of the line of vision the visible horizon gradually fades
off into the indistinctly presented “margin of consciousness”; the
“sensible present” shades away gradually at either end into the past
and the future. Yet, though thus not absolutely defined, sensible
space and time are never boundless.
(2) Perceptual space and time are both internally sensibly
continuous or unbroken. Concentrate your attention on any lesser
part of the actually seen expanse, and you at once find that it is itself
an expanse with all the characteristics of the wider expanse in which
it forms a part. Space as actually seen is not an aggregate of minima
visibilia or perceptual points in which no lesser parts can be
discriminated; so long as space is visually or tactually perceived at
all, it is perceived as containing lesser parts which, on attending to
them, are found to repeat the characteristics of the larger space. So
any part of the “specious present” to which special attention can be
directed, turns out itself to be a sensible duration. Perceived space is
made of lesser spaces, perceived time of lesser times; the “parts”
not being, of course, actually distinguished from each other in the
original percept, but being capable of being so distinguished in
consequence of varying movements of attention.
(3) On investigating the character of our actual perception of
space and time, it appears to contain two aspects, which we may call
the quantitative and the qualitative. On the one hand, whenever we
perceive space we perceive a certain magnitude of extension,
whenever we perceive time we perceive a longer or shorter lapse of
duration. Different spaces and different times can be quantitatively
compared in respect of the bigness of the extension or the duration
comprised in them. On the other hand, the percept of space or time
is not one of mere extension or duration. It has a very different
qualitative aspect. We perceive along with the magnitude of the
extension the form of its outline. This perception of spatial form
depends in the last resort upon perception of the direction assumed
by the bounding line or lines. Similarly, in dealing with only one
dimension of perceived space, we never perceive length (a spatial
magnitude) apart from the perception of direction (a spatial quality).
The same is true of the perception of time. The lapses of duration we
immediately perceive have all their special direction-quality; the
“specious present” is essentially a simultaneously presented
succession, i.e. a transition from before to after. It must be added
that, in perceptual space and time, the directions thus perceived
have a unique relation to the perceiving subject, and are thus all
qualitatively distinct and irreversible. Direction in space is estimated
as right, left, up, down, etc., by reference to axes through the centre
of the percipient’s body at right angles to each other, and is thus for
any given moment of experience uniquely and unambiguously
determined. Direction in time is similarly estimated with reference to
the actual content of the “focus of consciousness.” What is actually
focal is “now,” what is ceasing to be focal is “past,” what is just
coming to be focal is “future” in its direction.[142]
This is perhaps the most fundamental and important peculiarity of
the space and time of actual perception. All directions in them are
unambiguously determined by reference to the here and now of the
immediate experience of an individual subject. As a consequence,
every individual subject has his own special perceptual space and
time; Geometry and Mechanics depend, to be sure, on the possibility
of the establishment of correspondences between these spatial and
temporal systems, but it is essential to remember that, properly
speaking, the space and time system of each individual’s perception
is composed of directions radiating out from his unique here and
now, and is therefore individual to himself.[143]
§ 3. The Construction of the Conceptual Space and Time Order of
Science. For the purposes of practical life, no less than for the
subsequent object of scientific description of the physical order, it is
indispensably necessary to establish equations or correspondences
between the individual space and time systems of different
percipients. Apart from such correspondences, it would be
impossible for one subject to translate the spatial and temporal
system of any other into terms of his own experience, and thus all
practical intercourse for the purpose of communicating directions for
action would come to an end. For the communication of such
practical directions it is imperative that we should be able mentally to
reconstruct the spatial and temporal aspects of our experience in a
form independent of reference to the special here and now of this or
that individual moment of experience. Thus, like the rest of our
scientific constructions, the establishment of a single conceptual
space and time system for the whole of the physical order is
ultimately a postulate required by our practical needs, and we must
therefore be prepared to face the possibility that, like other
postulates of the same kind, it involves assumptions which are not
logically defensible. The construction is valuable, so far as it does its
work of rendering intercommunication between individuals possible;
that it should correspond to the ultimate structure of Reality any
further than the requirements of practical life demand is superfluous.
The main processes involved in the construction of the conceptual
space and time of descriptive science are three,—synthesis,
analysis, abstraction. (a) Synthesis. Psychologically speaking, it is
ultimately by the active movements of individual percipients that the
synthesis of the individual’s various perceptual spaces into one is
effected. As attention is successively directed, even while the body
as a whole remains stationary, to different parts of the whole
expanse before the eye, the visual space which was originally “focal”
in presentation becomes “marginal,” and the “marginal” focal by a
sensibly gradual transition. When to the movements of head and
eyes which accompany such changes in attention there are added
movements of locomotion of the whole body, this process is carried
further, and we have the gradual disappearance of originally
presented spaces from presentation, accompanied by the gradual
emergence of spaces previously not presented at all. This leads to
the mental construction of a wider space containing all the
individual’s different presentation-spaces, the order in which it
contains them being determined by the felt direction of the
movements required for the transition from one to another.
As we learn, through intercommunication with our fellows, of the
existence for their perception of perceptual extension never directly
presented to our own senses, the process of synthesis is extended
further, so as to comprise in a single spatial system all the
presentation-spaces of all the individual percipients in an order once
again determined by the direction of the movements of transition
from each to the others. Finally, as there is nothing in the principle of
such a synthesis to impose limits upon its repetition, we think of the
process as capable of indefinite continuance, and thus arrive at the
concept of a space stretching out in all directions without definite
bounds. This unending repetition of the synthesis of perceived
spaces seems to be the foundation of what appears in theory as the
Infinity of Space.
Precisely similar is the synthesis by which we mentally construct a
single time system for the events of the physical order. Now means
for me the content which occupies the centre of attentive interest. As
attention is concentrated on the different stages in the realisation of
an interest, this centre shifts; what was central becomes first
marginal and then evanescent, what was marginal becomes central.
Hence arises the conception of the events of my own inner life as
forming a succession of moments, with a determinate order, each of
which has been a now, or point of departure for directions in
perceptual time, in its turn. As with space so with time, the
intrasubjective intercourse of man with man makes it possible for me
mentally to extend this conceptual synthesis of moments of time so
as to include nows belonging to the experience of others which were
already past before the first now of their experiences which I can
synchronise with a now of my own, and again nows of their
experiences relatively to which the last now which synchronises with
one of my own is past. The indefinite repetition of such a synthesis
leads, as before with space, to the thought of a duration reaching out
endlessly into past and future, and thus gives us the familiar concept
of the Infinity of Time.[144]
(b) Analysis. Equally important is the part played by mental
analysis in the formation of the conceptual space and time system.
As we have already seen, successive attention to lesser parts of a
presented extension, or a presented lapse, reveals within each
lesser part the same structure which belongs to the whole, and thus
establishes the sensible continuity of space and time. In actual fact,
the process of attending successively to smaller and yet smaller
portions of space and time cannot, of course, be carried on
indefinitely, but we can conceptually frame to ourselves the thought
of the indefinite repetition of the process beyond the limits arbitrarily
imposed on it by the span of our own attention. Thus, by an act of
mental analysis, we arrive at the concept of space and time as
indefinitely divisible, or possessed of no ultimately unanalysable last
parts, which is an indispensable pre-requisite of Geometry and
Dynamics.
This indefinite divisibility of conceptual space and time is not of
itself enough, as is often supposed, to establish their continuity in the
strict mathematical sense of the word; their continuity depends upon
the further assumption that whatever divides a series of positions in
space or events in time unambiguously into two mutually exclusive
classes, is itself a position in the space or event in the time series.
This assumption does not seem to be absolutely requisite for all
scientific treatment of the problems of space and time,[145] but is
demanded for the systematic establishment of the correspondence
between the spatial and temporal series and the continuous series of
the real numbers. Moreover, it seems impossible to assign any
positive content to the notion of a something which should bisect the
spatial or temporal order without occupying a position in that order.
Hence we seem inevitably led by the same analytical process which
conducts us to the conception of the spatial and temporal orders as
infinite series to think of them also as continuous series in the strict
sense of the term. The alternative conception of them as
discontinuous, if not absolutely excluded, does not seem to be called
for by any positive motive, and is incompatible with the complete
execution of the purposes which demand application of the number-
series to a spatial or temporal content.
(c) Abstraction. The part played by abstraction in the formation of
the conceptual space and time order out of the data of perception is
often overlooked by theorists, but is of fundamental importance, as
we shall see immediately. We have already learned that the most
significant fact about the time and space order of individual
experience is that its directions are unique, because they radiate out
from the unique here and now of immediate feeling. In the
construction of the conceptual space and time order we make entire
abstraction from this dependence on the immediate feeling of a
subject. Conceptual space contains an infinity of positions, but none
of them is a here; conceptual time an infinity of moments, but none
of them is a now. As the time and space of the conceptual order are
taken in abstraction from the differences between individual points of
view, no one point in either can be regarded as having more claim
than any other to be the natural “origin of co-ordinates” with
reference to which directions are estimated. We shall have repeated
opportunity in the remainder of this chapter to observe how important
are the consequences of this abstraction.
Abstraction also enters in another way into the construction by
which conceptual space and time are created. Actual perceived
space and time are indeed never empty, but always filled with a
content of “secondary” qualities. In other words, they are always one
aspect of a larger whole of fact. Extension is never perceived apart
from some further visual or tactual quality of the extended, temporal
lapse never perceived without some change in presented content,
however slight. But in constructing the conceptual space and time
system, we abstract altogether from this qualitative aspect; we think
solely of the variety of positions and directions in time and space
without taking any account of the further qualitative differences with
which they are accompanied in concrete experience. Thus we come
by the notion of an empty space and an empty time as mere systems
of positions into which various contents may subsequently be put.
Strictly speaking, the notion of an empty space or an empty time is
unmeaning, as the simple experiment of thinking of their existence is
sufficient to show. We cannot in thought successfully separate the
spatial and temporal aspects of experience from the rest of the
whole to which they belong and take them as subsisting by
themselves, any more than we can take timbre as subsisting apart
from musical pitch or colour-tone from saturation. We can, however,
confine our attention to the spatial-temporal system of positions
without taking into account the special secondary properties of the
extended and successive. It is from this logical abstraction that the
illusion arises when we imagine an empty set of spatial and temporal
positions as having first to exist in order that they may be
subsequently “filled” with a variety of contents.[146]
§ 4. Characteristics of the Conceptual Time and Space Order. The
following characteristics of the conceptual space and time created by
the construction we have just examined, call for special notice.
Conceptual space and time are necessarily taken, for reasons
already explained, to be unlimited, and indefinitely divisible. Though
it does not seem inevitable that they should be continuous, we
appear to be unable to attach any positive meaning to the notion of
their discontinuity, and, in the practical need for the application to
them of the complete number-series, we have a valid positive ground
for taking them as continuous. But space and time are thus resolved,
in the process of their conceptual construction, into continuous
infinite series of which the terms are spatial and temporal positions
or points. Unlike the parts of perceptual space and time, these
conceptual terms are not themselves spaces or times, as they
contain no internal multiplicity of structure. Conceptual space and
time are thus not wholes or aggregates of parts, but systems of
relations between terms which possess no quantitative character.
Between any two terms of the spatial, or again of the temporal,
series there is one unique relation, which is completely determined
by the assignment of the terms, their distance. In the temporal
series, which has only one dimension, you can only pass from any
one given term to any other through a series of intermediate terms
which is once and for all determined when the initial and final terms
are given, hence nothing is required beyond the terms themselves to
fix their distance. The spatial series is multi-dimensional, i.e. you can
pass from any one term in it to any second by an indefinite variety of
routes through intermediate terms, but it is still true that there is one
and only one such route which is completely determined when the
terms in question are known, namely, the straight line passing
through both. This straight line constitutes the unique distance of the
two points from each other.[147] Thus the genuine concept of which
those of space and time are species is not that of magnitude or
quantity, but of serial order.
Further, and this is a point of fundamental difference between
conceptual space and time, and the spaces and times of immediate
perception, any one position in either order, taken by itself, is
qualitatively indistinguishable from any other. All points of space, all
moments of time, are alike, or, as it is also phrased, conceptual
space and time are homogeneous throughout. It is not until you take
at least two terms of the spatial or temporal series and consider the
relation they determine, that distinction becomes possible. This
homogeneity of conceptual space and time is an inevitable
consequence of the abstraction from the immediate feelings of the
individual subject of experience involved, as we saw, in the process
of their construction. In our actual perception of spatial and temporal
extension, that part of perceived space and time which stands in
direct unity with immediate feeling is qualitatively distinguished as
the here and now from all the rest, and thus does not depend upon
the specification of a second spatial or temporal position for its
recognisability. Here is where I am, now is this felt present. And
similarly, every other part of the actually presented space and time
gets a unique qualitative character from its special relation to this
here and now; it is right or left, behind or in front, before or after.
When we abstract altogether from the unique relation with individual
experience which thus makes the here and now of perception, as we
do in constructing our conceptual space and time order, every
position alike becomes the mere possibility of a here or a now, and
as such mere possibilities the various positions are indistinguishable.
Practically, this homogeneity is important as the indispensable
condition for the quantitative comparison of different portions of
extension or duration.
An apparently inevitable consequence of the homogeneity of
conceptual space and time is the relativity of spatial and temporal
position. As we have seen, positions in conceptual space and time
are not distinguishable until you take them in pairs. In other words, to
fix one position in space or one date you have to give its relation to
another position or date, and similarly to fix this you must specify a
third, and so on indefinitely. To say where A is means to say how you
get to it from B, and B again is only known by the way it is reached
from C, and so on without end. Logically, this is a simple
consequence of the nature of space and time as conceptually
analysed into endless series. To specify any term in the series you
must give the unique relation it bears to some other term, its logical
distance. And, in a series which has neither first nor last term, this
second term cannot be defined except by its logical distance from a
third. In actual perception this difficulty is avoided, owing to the fact
that immediate feeling gives us the here and now from which all our
directions are measured. But in conceptual space or time there is
nothing to distinguish any one here which we may take as our “origin
of co-ordinates,” or any one now which we take as our present from
any other, and hence the endless regress seems inevitable.
It follows, of course, that in conceptual space and time there is no
principle by which to distinguish different directions. In perception
they can be distinguished as right and left, up and down, and so
forth. But since what is right to one percipient is left to another, in
conceptual space, where complete abstraction is made from the
presence of an individual percipient, there is neither right nor left, up
nor down, nor any other qualitative difference between one direction
and another, all such differences being relative to the individual
percipient. When we wish to introduce into conceptual space
distinctions between directions, we always have to begin by
arbitrarily assigning some standard direction as our point of
departure. Thus we take, e.g., an arbitrarily selected line ——— as
A B
such a standard for a given plane, and proceed to distinguish all
other directions by the angle they make with A B and the sense in
which they are estimated (whether as from B to A or from A to B).
But both the line A B and the difference of sense between A B and B
A can only be defined by similar reference to some other standard
direction, and so on through the endless regress.
Similarly with conceptual time. Here, as there is only one
dimension, the difficulty is less obvious, but it is no less real. In
conceptual time there is absolutely no means of distinguishing
before from after, past from future. For the past means the direction
of our memories, the direction qualified by the feeling of “no longer”;
the future is the direction of anticipation and purposive adaptation,
the direction of “not yet.” And, apart from the reference given by
immediate feeling to the purposive life of an individual subject, these
directions cannot be discriminated. In short, conceptual time and
space are essentially relative, because they are systems of relations
which have no meaning apart from qualitative differences in the
terms which they relate; while yet again, for the purpose of the
conceptual construction which yields them, the terms have to be
taken as having no character but that which they possess in right of
the relations.[148]
One other feature of the space and time construction is sufficiently
important to call for special mention. Space and time are commonly
thought of as unities of some kind. All spatial positions, it is usually
assumed, fall within one system of space-relations; all dates have
their place in one all-inclusive time. This character of unity completes
the current conception of the spatial and temporal order. Each of
those orders is a unity, including all possible spatial or temporal
positions; each is an endless, infinite, continuous series of positions,
which all are purely relative. There are other peculiarities, especially
of the current concepts of space, with which it is not necessary to
deal here, as they are of an accidental kind, not arising out of the
essential nature of the process by which the conception is
constructed. Thus it is probably a current assumption that the
number of dimensions in space is three and no more, and again that
the Euclidean postulate about parallels is verified by its constitution.
As far as perceptual space is concerned, those assumptions
depend, I presume, upon empirical verification; there seems to be no
reason why they should be made for the conceptual space-order,
since it is quite certain that a coherent science of spatial relations
can be constructed without recourse to them.[149]
§ 5. The question now is, whether the whole of this spatial and
temporal construction is more than imperfect, and therefore
contradictory, appearance. I will first state in a general form the
arguments for regarding it as appearance, and then proceed to
reinforce this conclusion by dealing with some special difficulties.
Finally, I propose to ask whether we can form some positive
conception of the higher order of Reality of which the spatial and
temporal series are phenomenal.
That the space and time order is phenomenal and not ultimate,
can, I think, be conclusively shown by a general argument which I
will first enunciate in principle and then develop somewhat more in
detail. An all-comprehensive experience cannot apprehend the detail
of existence under the forms of space and time for the following
reason. Such an experience could be neither of space and time as
we perceive them, nor of space and time as we conceptually
reconstruct them. It would not be of perceptual space and time,
because the whole character of our perceptual space and time
depends upon the very imperfections and limitations which make our
experience fragmentary and imperfect. Perceptual space and time
are for me what they are, because I see them, so to say, in
perspective from the special standpoint of my own particular here
and now. If that standpoint were altered, so that what are actually for
me there and then became my here and now, my whole outlook on
the space and time order would suffer change. But the Absolute
cannot look at the space and time order from the standpoint of my
here and now. For it is the finitude of my interests and purposes
which confine me in my outlook to this here and now. If my interests
were not bound up in the special way in which they are with just this
special part or aspect of the life of a wider whole, if they were co-
extensive with the life of that whole, every place and every time
would be my here and now. As it is, here is where my body is, now is
this particular stage in the development of European social life,
because these are the things in which I am primarily interested. And
so with all the other finite experiences in which the detail of the
absolute experience finds expression. Hence the absolute
experience, being free from the limitations of interest which condition
the finite experiences, cannot see the order of existence from the
special standpoint of any of them, and therefore cannot apprehend it
under the guise of the perceptual space and time system.
Again, it cannot apprehend existence under the forms of space
and time as we conceptually reconstruct them. For Reality, for the
absolute experience, must be a complete individual whole, with the
ground of all its differentiations within itself. But conceptual space
and time are constructed by deliberate abstraction from the relation
to immediate experience implied in all individuality, and
consequently, as we have just seen, they contain no real principle of
internal distinction, their constituent terms being all exactly alike and
indistinguishable. In short, if the perceptual time and space systems
of our concrete experience represent individual but imperfect and
finite points of view, the conceptual space and time of our scientific
construction represents the mere abstract possibility of a finite point
of view; neither gives a point of view both individual and infinite, and
neither, therefore, can be the point of view of an absolute
experience. An absolute experience must be out of time and out of
space, in the sense that its contents are not apprehended in the form
of the spatial and temporal series, but in some other way. Space and
time, then, must be the phenomenal appearance of a higher reality
which is spaceless and timeless.
§ 6. In principle, the foregoing argument appears to me to be
complete, but, for the sake of readers who care to have its leading
thought more fully developed, it may be re-stated thus. Perceptual
space and time cannot be ultimately real as they stand. They are
condemned already by the old difficulty which we found in the notion
of reality as made up of qualities in relation. Perceptual space and
time are aggregates of lesser parts, which are themselves spaces
and times; thus they are relations between terms, each of which
contains the same relation once more in itself, and so imply the now
familiar indefinite regress.[150] Again, when we try in our conceptual
space and time construction to remedy this defect by reducing space
and time altogether to mere systems of relations, the difficulty turns
out to have been merely evaded by such a process of abstraction.
For, so long as we keep rigidly to our conceptual construction, the
terms of our relations are indistinguishable. In purely conceptual
space and time, as we have seen, there is no possibility of
distinguishing any one direction from any other, since all are
qualitatively identical.
Indeed, it is obvious from first principles that when the sets of
terms between which a number of relations of the same type holds
are indistinguishable, the relations cannot be discriminated. To
distinguish directions at all, we must, in the end, take at least our
starting-point and one or more standard directions reckoned from it
—according to the number of dimensions with which we are dealing
—as independently given, that is, as having recognisable qualitative
differences from other possible starting-points and standard
directions. (Thus, to distinguish before and after in conceptual time,
you must at least assume some moment of time, qualitatively
recognisable from others, as the epoch from which you reckon, and
must also have some recognisable qualitative distinction between
the direction “past” and the direction “future.”) And with this reference
to qualitative differences we are at once thrown back, as in the case
of perceptual time and space, on the insoluble old problem of Quality
and Relation. The assumed starting-point and standard directions
must have qualitative individuality, or they could not be
independently recognised and made the basis for discrimination
between the remaining directions and positions: yet, because of the
necessary homogeneity of the space and time of conceptual
construction, they cannot have any such qualitative individuality, but
must be arbitrarily assumed. They will therefore themselves be
capable of determination only by reference to some other equally
arbitrary standard, and thus we are once more committed to the
indefinite regress. The practical usefulness of these constructions
thus depends on the very fact that we are not consistent in our use
of them. In all practical applications we use them to map out the
spatial and temporal order of events as seen in perspective from a
standpoint which is, as regards the conceptual time and space order
itself, arbitrary and indistinguishable from others.
§ 7. Instead of further elaborating this general argument, a task
which would be superfluous if its principle is grasped, and
unconvincing if it is missed, I will proceed to point out one or two
special ways in which the essential arbitrariness of the spatial and
temporal construction is strikingly exemplified. To begin with, a word
may be said about the alleged unity of space and time. It is
constantly taken for granted, by philosophers as well as by practical
men, that there can be only one spatial and one temporal order, so
that all spatial relations, and again all temporal relations, belong to
the same system. Thus, if A has a spatial relation to B and C to D, it
is assumed that there must be spatial relations between A and C, A
and D, and B and C, B and D. Similarly if A is temporally related with
B, and C with D. This view is manifestly presupposed in the current
conception of Nature, the “physical universe,” the “physical order,” as
the aggregate of all processes in space and time. But there seems to
be no real logical warrant for it. In principle the alleged unity of all
spatial and temporal relations might be dismissed, on the strength of
the one consideration that space and time are not individual wholes,
and therefore can contain no principle of internal structural unity.
This is manifest from the method by which the space and time of our
conceptual scheme have been constructed. They arose, as we saw,
from the indefinite repetition of a single type of relation between
terms in which we were unable to find any ultimately intelligible
principle of internal structure. But unity of structure cannot be
brought into that which does not already possess it by such mere
endless repetition. The result of such a process will be as internally
incoherent and devoid of structure as the original data. Hence space
and time, being mere repetitions of the scheme of qualities in
relation, cannot be true unities.
This becomes clearer if we reflect on the grounds which actually
warrant us in assigning position in the same space and the same
time to a number of events. For me A and B are ultimately in the
same space when there is a way of travelling from A to B; they are in
the same time when they belong to different stages in the
accomplishment of the same systematic purposes. Thus in both
cases it is ultimately from relation to an identical system of purposes
and interests that different sets of positions or events belong to one
space or one time. The unity of such a space or time is a pale
reflection in abstract form of the unity of a life of systematic purpose,
which is one because it has unique individual structure. It is in this
way, from the individual unity of the purpose and interests of my
ordinary waking life, that I derive the right to refer its experiences to
a single space and time system. Similarly, it is in virtue of the
inclusion of my own and my fellow-men’s purposes in a wider whole
of social systematic purpose that I can bring the space and time
relations of their experience into one system with my own. And
again, the sensible occurrences of the physical order belong to one
space and time with the space and time relations of human
experience, because of the varying ways in which they condition the
development of our own inner purposive life. But there are cases,
even within our own conscious life, where this condition appears to
be absent, and in these cases we do not seem to be able to make
intelligible use of the conception of a single time or a single space.
Take the case of our dreams. The events of my dreams stand in
spatial and temporal relations within the dream itself, but there would
be no sense in asking what are the spatial relations between the
places seen in my dreams and the places marked on the map of
England; or what are again the temporal relations between the
events of last night’s dream and those of this morning, or those of
the dreams of last week. Precisely because there is usually no
systematic identity of purpose connecting the dream with the waking
life or with other dreams, the time and space of the dream have no
position with respect to the time and space system of waking life, nor
those of one dream with relation to those of another.[151] Of course, it
may be said that the dream-space and dream-time are “imaginary,”
but the problem cannot be got rid of by the use of an epithet. To call
them imaginary is merely to say that they are not systematically
connected with the time and space of waking life, not to disprove
their genuineness as actual space and time constructions.
Similarly, if there are intelligent purposes of which our human
purposive life is debarred from taking account as such, as we urged
that there must be behind the phenomenal physical order, the time
and space within which those purposes are conceived and executed
would have no place in our spatial and temporal system. The
phenomenal events of the physical order would fall within our
system, but not the life of inner purpose of which that order is the
manifestation to our senses. Ultimately, in fact, all spaces and all
times could only form one spatial and temporal system on condition
that the infinite absolute experience views all its contents in spatial
and temporal form; then the various space and time systems
corresponding to the purposes of the various groups of finite
individuals would finally, for the infinite individual, form one great
system of time and space relations. But we have already seen that
the infinite experience cannot comprehend its contents in spatial or
temporal forms.
We infer, then, that there may be—indeed, if our interpretation of
the physical order is valid, there must be—a plurality of spaces and
times within the Real. Within any one such space or time all its
members are spatially and temporally interrelated, but the various
spaces are not themselves related in space, nor the various times
before or after one another in time. Their relation is the purely logical
one of being varying modes of the expression in a finite detail of the
underlying nature of the ultimate Reality.[152] For the absolute
experience they must be all at once and together, not in the sense of
being in “one space and time,” but in the sense of forming together
the systematic embodiment of one coherent ground or principle.
§ 8. Similar consequences, as to the phenomenal character of
space and time, follow from the consideration of the familiar Kantian
antinomies founded upon the concept of spatial and temporal infinity.
Space and time must be externally boundless and internally
indefinitely divisible, and yet again cannot be either. Freed from
unessential accessories, the argument for either side of the antinomy
may be stated thus. Space and time must be boundless because all
spatial and temporal existence means spatial and temporal relation
to a second term, itself similarly related to a third term. For precisely
the same reason both must be indefinitely divisible. Yet again, they
can be neither, since only the individual exists, and within such an
interminable network of relations between terms which are nothing
but the supporters of these relations there is no principle of individual
structure.[153] Thus the Kantian antinomies are a simple consequence
of the old difficulty about quality and relation. Space and time must
be mere relations, and the terms of those relations therefore
qualitatively indistinguishable; again, since they are relations they
cannot be relations between nothings or, what is the same thing,
between terms with no individual character. As in all cases where the
problem of relation and quality arises, it then conducts us to the
indefinite regress.
So long as we continue to look upon space and time as real, we
have therefore to choose between two equally illogical alternatives.
We must either arbitrarily refuse to continue the indefinite regress
beyond the point at which its difficulties become apparent, as is done
by the assertion that space and time have finite bounds or indivisible
parts, or we must hold that the absolute experience actually
achieves the summation of an unending series. With the recognition
that space and time are phenomenal, the result of a process of
construction forced on us by our practical needs, but not adequately
corresponding to the real nature of individual existence, the difficulty
disappears. Both sides of the antinomy become relatively true, in the
sense that for our practical purposes we must be content to adopt
now the one and again the other; both become ultimately untrue in
the sense that space and time, being constructions of our own, are
really neither finite nor infinite series, but are the one or the other
according to the purposes for which we use our construction.
§ 9. If spatial and temporal position and direction must thus in the
end be appearance, phenomenal of some more individual reality, we
have finally to ask, Of what are they the appearance? It is not
enough to say “of ultimate Reality,” or “of the Absolute.” Ultimately
this is, no doubt, true of space and time, as it is of everything else,
but we desire further to know if they are not proximately the
appearance of some special features of the inner physical life of the
lesser individuals which compose the Absolute. We naturally look for
some third term, in the nature of finite individuality, to mediate
between the structureless abstract generality of space and time
relation, and the perfect individual structure of the spaceless and
timeless Absolute Individual. We want, in fact, to connect the spatial
and temporal form which our experience wears, with some
fundamental aspect of our nature, as beings at once individual and
finite.
Nor is it particularly difficult to make the connection. When we
remember that space and time, as they actually condition our
perception and movement, are the space and time which radiate out
from an unique here and now of immediate feeling, it is fairly evident
that the spatial and temporal aspect of our experience is, as already
suggested, a consequence of that limitation of our attentive interests
which constitutes our finitude. It is the narrowness of my interests, or
at least of those which are sufficiently explicit to rise into the “focus”
of consciousness, that is reflected in the distinction of my here from
all the theres which are around me. Here is where my body is,
because of the specially intimate connection of the realisation of my
interests and purposes with those events in the phenomenal physical
order which I call the state of my body. Were my interests widened

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